Step 1 of 4 - Personal Information 25% Step-1 Personal InformationFirst Name*Last Name*Date of Birth Date Format: MM slash DD slash YYYY Other Name (If Applicable)Social Security Number CURRENT ADDRESSStreet*Apart NumberCity*State*Zip*Time Spent at This Address* PREVIOUS ADDRESSStreetApart NumberCityStateZipTime Spent at This AddressHome Phone*Cell PhoneOther PhoneEmail* If hired, can you provide proof of legal right to work in the US?*YesNoPosition Applying for Administrative RN Regional DON LPN HHA PCA Homemaker PT/OT/RT MSW Clerical Other Referral SourceWalk-InGovernment Employment AgencyEmployeeRelativeSchoolPersonOther Step-2 Education HistoryHigh School Name and AddressDid You Graduate?YesNoCourse of MajorDiploma or DegreeYear CompletedCollege Name and AddressDid You Graduate?YesNoCourse of MajorDiploma or DegreeYear CompletedGraduate School Name and AddressDid You Graduate?YesNoCourse of MajorDiploma or DegreeYear CompletedBusiness School Name and AddressDid You GraduateYesNoCourse MajorDiploma or DegreeYear CompletedTraining Program Name and AddressDid You Graduate?YesNoCourse MajorDiploma or DegreeYear Completed Step-3 Previous Work HistoryPrevious Employer NameAddressPhoneStart DateEnd DateJob TitleSupervisor's NameSalaryReason for LeavingPrevious Employer NameAddressPhoneStart DateEnd DateJob TitleSupervisor's NameSalaryReason for LeavingPrevious Employer NameAddressPhoneStart DateEnd DateJob TitleSupervisor's NameSalaryReason for Leaving Additional ReferencesNameAddress / Phone NumberRelationshipNameAddress / Phone NumberRelationshipNameAddress / Phone NumberRelationship Step-4 AvailabilityHHA Hours Available (Check all that apply) 4 Hours (AM) 4 Hours (PM) 8 Hours 12 Hours (AM) 12 Hours (PM) Live-in Applying For : Full Time Part Time I Prefer ; Days Evenings I am flexible Enter Your Available Hours BelowMondayTuesdayWednesdayThursdayFridaySaturdaySundayWill you work overtime (if required)YesNoIf no, please explainPosition DesiredSalary DesiredDate you can start Date Format: MM slash DD slash YYYY Have you ever been bonded?YesNoIf yes, by whom?Have you ever been convicted of a crime?YesNoIf yes, please explain Professional LicencesProfessionLicense No:Exp. Date:Verification Date / PersonHave you ever been sanctioned by Medicare / Medicaid?YesNoSchool / Training Program:Para-Professional Education: HHA PCA Verification Date / PersonList any foreign language(s) other than English and your skill level.List any additional information you would like us to consider.I certify that the information given by me is true and correct and without any omission. I understand and agree that any false statement or intentional omission on this application or any subsequently furnished from constitutes cause for discharge at any time during my employment by At Home Personal Care Services, LLC. (AHPCS) I authorize AHPCS investigate all statements made in this application. I further authorize AHPCS to make any investigation of my credit, criminal and driving records in connection with this application and anytime thereafter in connection with my employment. I authorize the references listed in this application, to provide AHPCS will all information concerning my previous employment and any other pertinent information about me that they may have. I understand that all information obtained during pre-employment screening is held by AHPCS in confidence and will not be released to a third party unless AHPCS is required by law or is specifically authorized to do so by me. I further understand that if I am hired, I will not have an employment contract and that my employment and compensation can be changed or terminated with or without notice or cause at any time by AHPCS. AHPCS is an equal opportunity employer. We do not discriminate because of age, race, creed, color, sexual orientation, disability, citizenship status, national origin, marital status, veterans status or the presence of a non-job related medical condition or handicap or any other legally protected status.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.